Healthy People 2020: Who’s Leading the Leading Indicators? Carter Blakey Deputy Director, Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services Who’s Leading the Leading Health Indicators?

• Leading Health Indicators are: o Critical health issues that, if addressed appropriately, will dramatically reduce the leading causes of preventable deaths and illnesses o Linked to specific Healthy People objectives o Intended to motivate action to improve the health of the entire population 1200 Healthy People objectives

LHIs are a subset of Healthy People objectives

3 Who’s Leading the Leading Health Indicators?

Featured Speakers:

• Don Wright, MD, MPH – Director, Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services

• Norma Harris, PhD, MSPH - Senior Advisor, Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention

• Jenny McFarlane - HIV Prevention Manager, Texas Department of State Health Services

4 Don Wright, MD, MPH Director, Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services Importance of and Sexual Health

• Reproductive and sexual health is critical to the overall health and quality of life for both men and women.

• Regular and reliable access to reproductive and sexual health services may reduce the rates of HIV and other sexually transmitted diseases (STDs), infertility, fetal and prenatal health problems, and .

• Access to reproductive health services may reduce overall healthcare costs by screening for reproductive , STDs intimate partner violence, and substance use disorders.

6 Reproductive Health and Sexual Health Leading Health Indicators

• Sexually active females receiving reproductive health services (FP-7.1)

• Knowledge of among HIV-positive persons (HIV-13)

7 HIV: Know Your Status

• Everyone should get tested at least once, and people at high risk should be tested at least once a year.

• Knowledge of HIV status can begin the process of linkage to care.

• Knowledge of HIV status can serve as a tool for prevention.

8 Receipt of Reproductive Health Services in the Past 12 Months among Sexually Active Females Aged 15–44, 2011–2015

NOTES: I = 95% confidence interval. Data are for females aged 15 to 44 years who are sexually active (had sex in the past 3 months) and have received at least one of the following reproductive health services in the past 12 months: a method; birth control counseling; birth control checkup or test; counseling; emergency contraception counseling; pelvic exam; pap smear; test; and STD counseling, testing, or treatment. Persons of Hispanic origin may be any race. Single race categories are for persons who reported only one race group. SOURCE: National Survey of Family Growth (NSFG), CDC/NCHS. Obj. FP-7.1 HIV Serostatus Awareness Among Persons Aged 13+ Living with HIV, 2015

NOTES: *2010 Total = HP2020 baseline. Data are for persons aged 13 years and over who were aware of their HIV . Persons of Hispanic origin may be any race. American Indian includes Alaska Native. Native Hawaiian includes other Pacific Islander. The Asian category includes Asian/Pacific Islander legacy cases (cases that were diagnosed and reported under the old Office of Management and Budget race/ethnicity classification system). Respondents were asked to select one or more races. Single race categories are for persons who reported only one race group. Obj. HIV-13 SOURCE: National HIV Surveillance System (NHSS), CDC/NCHHSTP. Healthy People 2020 Leading Health Indicator: Knowledge of HIV Status

Norma Harris, PhD Senior Advisor Strategic Indicators and Data for Impact Division of HIV/AIDS Prevention Centers for Disease Control and Prevention Estimated HIV and among Persons Aged ≥13 Years, 2010–2015, United States

Note. Estimates were derived from a CD4 depletion model using HIV surveillance data. *Difference from the 2010 estimate was deemed statistically significant (p < .05). Source: CDC Estimated Incidence and Prevalence, 2018. HIV Care Continuum Outcomes, 2015—United States

Note. Receipt of medical care was defined as ≥1 test (CD4 or VL) in 2015. Retained in continuous medical care was defined as ≥2 tests (CD4 or VL) ≥3 months apart in 2015. Viral suppression was defined as <200 copies/mL on the most recent VL test in 2015. Source: CDC Monitoring Report, 2018. HIV Care Continuum Outcomes, 2015—United States

Note. Receipt of medical care was defined as ≥1 test (CD4 or VL) in 2015. Retained in continuous medical care was defined as ≥2 tests (CD4 or VL) ≥3 months apart in 2015. Viral suppression was defined as <200 copies/mL on the most recent VL test in 2015. Source: CDC Monitoring Report, 2018. Knowledge of HIV Status among Persons Aged ≥13 Years Living with HIV Infection, 2010-2015--United States

83.1% 85.5%

Note. Estimates were derived from a CD4 depletion model using HIV surveillance data. Denominator includes persons living with diagnosed and undiagnosed HIV infection. Source: *Difference from the 2010 estimate was deemed statistically significant (P < .05). Source: CDC Estimated Incidence and Prevalence, 2018. Importance of Knowledge of HIV Status

CDC Monitoring Report 2016; CDC Vital Signs 2017; Gopalappa, 2017 16 Importance of Knowledge of HIV Status

. In 2017, 38,739 people in the US received an HIV diagnosis

1 in 2 people had been living with HIV for 3 years before diagnosis

CDC Vital Signs, 2017 Importance of Knowledge of HIV Status

CDC Vital Signs, 2017 18 CDC’s Strategic Priorities What CDC is doing to Increase Knowledge of Status

. Promoting the implementation of guidelines for HIV testing

Clinical setting Non-clinical setting

. Improving testing methods HIV-13 What CDC is doing to Increase Knowledge of Status

. Promoting routine screening and targeted testing – State and local health departments and community based organizations

~3,000,000 DHAP funded HIV tests, 2016

~12, 500 new HIV positives persons identified

Note: DHAP funded tests occur in the 61 CDC-funded jurisdictions in the United States, Puerto Rico, and the U.S. Virgin Islands. Source: CDC-Funded HIV Testing Report, 2016 What CDC is doing to Increase Knowledge of Status

. Promoting HIV testing through Campaigns (Act Against AIDS)

Providers HIV-13 What CDC is doing to Increase Knowledge of Status

. Promoting HIV testing through Campaigns (Act Against AIDS)

Providers ConsumersHIV-13 Summary

. Knowledge of status is the 1st step to the HIV Care Continuum, a series of steps that are needed to get to the ultimate outcome of HIV treatment, viral suppression – Can only be achieved through HIV testing . HIV testing is the gateway to lifesaving treatment and prevention . Increases in HIV prevalence increase potential for ongoing HIV transmission . To get to the 2020 national goal of 90%, enhanced efforts are needed to reduce diagnosis delays and missed opportunities for HIV testing – Creating systems in clinical settings to implement routine HIV screening to identify undiagnosed HIV persons – Providing guidance and training on conducting HIV testing in clinical and non- clinical settings – Working with providers and consumers to reduce bias and stigma related to HIV testing – Understanding why persons are not being diagnosed soon after infection For more information, please visit: https://www.cdc.gov/hiv/testing/index.html

Division of HIV/AIDS Prevention Knowledge of serostatus among persons living with HIV in Texas

HIV Prevention and Program Evaluation Groups Jenny R. McFarlane, Sarah Norkin, Justin Irving, Ann S. Robbins New HIV Diagnoses, Persons Living with HIV, and Deaths in Texas (1980-2017)

*There is a two-year lag in availability of complete death data

Estimated 18,400 Texans do not know that they are living with HIV

11/26/2018 29 Proportion of all Texans with HIV who had diagnosed HIV was significantly higher in 2016 compared to 2010- 2012

KNOW THEIR STATUS

11/26/2018 30 In 2016, 7 out of 10 Texans with undiagnosed HIV infections were MSM

11/26/2018 31 Texas’ Strategies to Increase Knowledge of HIV Status

11/26/2018 32 Strategies

• Follow-Up • Lowest volume, most focused, related to disease investigation • Focused Testing • Moderate Volume, focuses on priority populations, out in the field • Routine Screening • Highest volume, no focus, occurs in health care settings, routine, opt-out, integrated

11/26/2018 33 Focused and Routine HIV testing

Focused testing Routine screening

Persons at very high risk of People getting routine health Who is the focus? acquiring HIV infections care

Health care settings in areas with high numbers of new HIV Areas and populations with Where is it diagnoses and PLWH and that high numbers of new HIV appropriate? serve high number of diagnoses and PLWH uninsured, Black, and Hispanic persons

>1% of persons tested will Productivity At least 0.1% of persons get a first-time diagnosis expectation tested will have a positive test (new positive) 11/26/2018 35 Strategies

• Matching testing data to established data systems to validate new or previous diagnosis and care • Expand PrEP services • More frequent testing and earlier diagnosis • Cluster Response • Leading to more frequent testing of high priority populations and implementation of interventions • Public Health Detailing • Communicating directly with medical providers • Public Health Campaigns • Greater than AIDS

11/26/2018 36 11/26/2018 37 Increase Testing Improve Focused Testing 2015-2017 Previous and New Diagnoses Where positives are diagnosed in Routine, new vs. previous 2015-2017 Patient Profile for New Diagnoses: Birth Sex Patient Profile for New Diagnoses: Age Group Patient Profile for New Diagnoses: Race/Ethnicity Next Steps

• Evaluation Questions • Level of investment? • Responsive to epidemic? • Productivity? • Reducing undiagnosed infections? • Community Engagement and Planning • Effective strategies for marketing and engagement • Address bias, stigma, and disparities

90 percent of all persons living with HIV know their status.

Achieving Together: A Community Plan to End the Epidemic in Texas

11/26/2018 45 Thank you

Sarah Norkin, MPH Ann S. Robbins, PhD Justin P. Irving Jenny R. McFarlane Roundtable Discussion

47 Stay Connected

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